At the conclusion of every laparoscopic procedure, cannulae should be removed one by one under direct laparoscopic control while the abdominal wall puncture sites are inspected for hemostasis. As each cannula is removed, an assistant should plug the puncture site with a finger to maintain the low-pressure pneumoperitoneum. After all can-nulae are removed except the one housing the laparoscope, the laparo-scope is withdrawn 4-5 cm into the cannula and this cannula then is slowly withdrawn from the body wall as the surgeon inspects the edges of the abdominal wall for hemostasis.
Because we have seen some symptomatic hernias through 10-mm incisions, all body wall incisions from 10/12-mm cannulae should be closed using conventional techniques or with a transabdominal suture while the cannula is still in place.6 For this purpose, a needle is available that resembles the Veress needle except its inner blunt-tipped cannula looks similar to a crochet needle and can be extended beyond the sharp needle tip to grasp a fascial stitch (see Chapter 2). The needle is equipped with the fascial suture and then initially passed through the fascia and peritoneum about 5-7 mm from a cannula (Figure 6.31). The loop of the suture is released under laparoscopic visual control, grasped by a grasper placed at another site, and the needle is removed (Figure 6.32). The needle is then reinserted through the abdominal wall on the other side of the cannula and used to grasp the loop of the suture (Figure 6.33). The suture is pulled back up through the abdominal wall
Figure 6.33. Cannula wound closure. The second puncture by the SuturePasser permits extraction of the suture and fascial closure.
with the needle, and the cannula removed, hemostasis is checked, and the suture is tied to close the peritoneum, muscle layer, and fascia en mass. When using this technique of cannula site closure, at least three cannulae should remain in the abdominal cavity until all cannula sites have had sutures placed - one site is needed for the laparoscope and one for a grasping device while the third site is being closed. We recommend placing all necessary stitches at the beginning of the operation, just after completing all laparoscopic cannulae placements (Figure 6.34). The fascial/peritoneal defects are closed by tying the previously placed sutures after desufflation of the abdomen. Lastly, the skin is closed with skin staplers, adhesive strips (such as Steri-Strips), or skin adhesives (e.g., Dermabond™; Ethicon), with/without absorbable subcutaneous sutures.
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